Who's Reading Your X-Ray?

By ANDREW POLLACK

Published: November 16, 2003

SANJAY SAINI was not prepared for the hate mail. A radiologist at Massachusetts General Hospital, Dr. Saini thought he had found a clever way to relieve an acute shortage of specialists who could read X-rays and M.R.I. scans. The hospital would beam images electronically from some scans to India, to be worked on by radiologists there.

But the arrangement, made late last year with a company in India, has touched off a minor furor. It turns out that even American radiologists, with their years of training and annual salaries of $250,000 or more, worry about their jobs moving to countries with lower wages, in much the same way that garment knitters, blast-furnace operators and data-entry clerks do.

Since the news got out, Dr. Saini has received a flurry of angry e-mail messages, most of them anonymous, urging him to stop. The American College of Radiology, the professional group for the country's 30,000 radiologists, has set up a task force to look at the offshore transfer of radiology services. And the online discussion groups of AuntMinnie.com, a Web site for radiologists, have been buzzing with debate about the prospects for competition from ''radiology sweatshops'' abroad.

''This teleradiology thing is another nail in the coffin of the job market,'' wrote someone on the Web site who identified himself as a radiologist. ''Who needs to pay us $350,000/yr if they can get a cheap Indian radiologist for $25,000/yr.''

Daniel Courneya, a radiologist in Hibbing, Minn., fumed on the site that Massachusetts General, a Harvard teaching hospital known to its admirers as ''Man's Greatest Hospital,'' should instead be called ''Money Grubbing Hospital,'' another play on its initials.

On the surface, the controversy may seem a bit odd. Experts say that the number of X-rays from the United States now being read in India is minuscule and that regulatory restrictions are likely to keep it from growing rapidly. Moreover, most hospital jobs, unlike those in radiology, require close patient contact, so there is a limit to how much offshore outsourcing can be done.

Besides, employment in American health care has been growing. In the 12 months ended in August, the category added about 250,000 jobs while overall nonfarm payroll jobs shrank by nearly 500,000. Hospitals alone added about 70,000 jobs in that period.

Still, Dr. Saini's plan shows that even medical care, the most intimate and localized of services, is grappling with the globalization that has moved many jobs -- first in manufacturing and more recently in white-collar work -- across the ocean. And in health care, of course, there is more at stake than jobs. Dr. Courneya and other critics worry that radiologists outside the United States may not be trained properly, endangering patients' safety.

Dr. Saini says that the furor is much ado about nothing, that people are reacting based on emotion, not fact. A native of India who has lived in the United States since he was in high school, he said that any Indian radiologist reading scans from Massachusetts General would have to be licensed in that state and be certified by the hospital, so patient care would not suffer.

At the moment, he said, there are no such qualified radiologists at the outpost in India, so actual diagnoses are not being made there. Rather, the radiologists in India are converting two-dimensional images from scans into three-dimensional pictures that are more understandable to surgeons; that job is usually done by technicians in the United States.

RADIOLOGY is not the only medical service that may someday be performed for Americans by people in other countries. Other candidates are the analysis of tissue samples, the reading of electrocardiograms, the monitoring of intensive care units and even robotic surgery.

Back-office medical work has been moving offshore for several years now, particularly to India, which has a large number of educated English-speaking people. Though the number of affected jobs is only a small fraction of the total, many experts say the share is growing as hospitals face pressure to cut costs.

For example, when doctors at Children's Hospital of Wisconsin in Milwaukee dictate information about a patient's condition, their words are sometimes whisked electronically to India, where trained medical transcriptionists type them and send them back, to be incorporated into the patient's medical record.

Then there is Botsford General Hospital in Farmington Hills, Mich., which uses a company with operations in India to help collect unpaid bills. ''They came in with a rate that is less than half of what a U.S.-based collection agency would charge me,'' said Luke Meert, corporate director for accounts receivable at Botsford Health Care Continuum, the parent company.

Coding -- the assignment of numbers for medical procedures to bills -- is also heading offshore. The American Academy of Professional Coders now has chapters in India. Some insurance-claims processing is moving, too: Aetna Inc., the health insurance giant, has 400 people in that country.